ESPEN Guidelines on Parenteral Nutrition: Central Venous ...
Clinical Nutrition 28 (2009) 365?377
Contents lists available at ScienceDirect
Clinical Nutrition
journal homepage:
ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis and therapy of complications)
Mauro Pittiruti a, Helen Hamilton b, Roberto Biffi c, John MacFie d, Marek Pertkiewicz e
a Catholic University Hospital, Roma, Italy b John Radcliffe Infirmary, Oxford, United Kingdom c Division of Abdomino-Pelvic Surgery, European Institute of Oncology, Milano, Italy d Scarborough Hospital, Scarborough, United Kingdom e Medical University of Warsaw, Poland
article info
Article history: Received 4 February 2009 Accepted 31 March 2009
Keywords: Guidelines Evidence-based Clinical practice Parenteral nutrition Central venous access Venous access devices Midline catheters PICC Central venous catheters Totally implantable ports Tunneled catheters Peripheral parenteral nutrition Home parenteral nutrition Ultrasound guidance Catheter-related bloodstream infection Needle-free connectors Chlorhexidine Antibiotic lock therapy Exchange over guide wire Heparin lock Sutureless securing devices Catheter-related venous thrombosis Pinch-off syndrome Fibrin sleeve
summary
When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, nontunneled central venous catheters, through peripherally inserted central catheters (PICC), or ? for limited period of time and with limitation in the osmolarity and composition of the solution ? through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or ? if planned for an extended or unlimited time ? long-term venous access devices (tunneled catheters and totally implantable ports). The most appropriate site for central venous access will take into account many factors, including the patient's conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure. Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary. Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.
? 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved.
General recommendations about the indications for and the use of the different types of venous access devices available for parenteral nutrition
1. What is the role of peripheral parenteral nutrition?
Central venous access (i.e.,venous access which allows delivery of nutrients directly into the superior vena cava or the right
E-mail address: espenjournals@.
atrium) is needed in most patients who are candidates for parenteral nutrition (PN).
In some situations however PN may be safely delivered by peripheral access (short cannula or midline catheter), as when using a solution with low osmolarity, with a substantial proportion of the non-protein calories given as lipid.
It is recommended (Grade C) that peripheral PN (given through a short peripheral cannula or through a midline catheter) should be used only for a limited period of time, and only when using nutrient solutions whose osmolarity does not exceed 850 mOsm/L.
0261-5614/$ ? see front matter ? 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2009.03.015
366
M. Pittiruti et al. / Clinical Nutrition 28 (2009) 365?377
Summary of statements: Central Venous Catheters
Subject
Choice of route for intravenous nutrition
Recommendations
Central venous access (i.e., venous access which allows delivery of nutrients directly into the superior vena cava or the right atrium) is needed in most patients who are candidates for parenteral nutrition (PN). In some situations however PN may be safely delivered by peripheral access (short cannula or midline catheter), as when using a solution with low osmolarity, with a substantial proportion of the non-protein calories given as lipid. It is recommended that peripheral PN (given through a short peripheral cannula or through a midline catheter) should be used only for a limited period of time, and only when using nutrient solutions whose osmolarity does not exceed 850 mOsm/L. Home PN should not normally be given via short cannulas as these carry a high risk of dislocation and complications. Peripheral PN, whether through short cannulas or midline catheters, demands careful surveillance for thrombophlebitis.
Grade C
Number 1
Choice of PN catheter device
Short-term: many non-tunneled central venous catheters (CVCs), as well as peripherally inserted central
B
2
catheters (PICCs), and peripheral catheters are suitable for in-patient PN.
Medium-term: PICCs, Hohn catheters, and tunneled catheters and ports are appropriate. Non-tunneled central
venous catheters are discouraged in HPN, because of high rates of infection, obstruction, dislocation, and
venous thrombosis.
Prolonged use and HPN (>3 months) usually require a long-term device. There is a choice between tunneled
catheters and totally implantable devices. In those requiring frequent (daily) access a tunneled device is
generally preferable.
Choice of vein for PN
The choice of vein is affected by several factors including venepuncture technique, the risk of related
C
3
mechanical complications, the feasibility of appropriate nursing of the catheter site, and the risk of thrombotic
and infective complications.
The use of the femoral vein for PN is relatively contraindicated, since this is associated with a high risk of
contamination at the exit site in the groin, and a high risk of venous thrombosis.
High approaches to the internal jugular vein (either anterior or posterior to the sternoclavicular muscle) are
not recommended, since the exit site is difficult to nurse, and there is thus a high risk of catheter
contamination and catheter-related infection.
Insertion of CVCs
There is compelling evidence that ultrasound-guided venepuncture (by real-time ultrasonography) is
A
4
associated with a lower incidence of complications and a higher rate of success than `blind' venepuncture.
Ultrasound support is therefore strongly recommended for all CVC insertions. Placement by surgical cutdown
is not recommended, in terms of cost-effectiveness and risk of infection.
In placement of PICCs, percutaneous cannulation of the basilic vein or the brachial vein in the midarm, utilizing B
4
ultrasound guidance and the micro-introducer technique, is the preferred option
Position of CVC tip
High osmolarity PN requires central venous access and should be delivered through a catheter whose tip is in C, B
5
the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium
(Grade A). The position of the tip should preferably be checked during the procedure, especially when an
infraclavicular approach to the subclavian vein has been used.
Postoperative X-ray is mandatory (a) when the position of the tip has not been checked during the procedure,
and/or (b) when the device has been placed using blind subclavian approach or other techniques which carry
the risk of pleuropulmonary damage.
Choice of material for CVC
There is limited evidence to suggest that the catheter material is important in the etiology of catheter-related B
6
sepsis. Teflon, silicone and polyurethane (PUR) have been associated with fewer infections than polyvinyl
chloride or polyethylene. Currently all available CVCs are made either of PUR (short-term and medium-term)
or silicone (medium-term and long-term); no specific recommendation for clinical practice is made.
Reducing the risk of catheter-related infection
Evidence indicates that the risk of catheter-related infection is reduced by: Using tunneled and implanted catheters (value only confirmed in long-term use) Using antimicrobial coated catheters (value only shown in short-term use) Using single-lumen catheters Using peripheral access (PICC) when possible Appropriate choice of the insertion site Ultrasound-guided venepuncture Use of maximal barrier precautions during insertion Proper education and specific training of the staff An adequate policy of hand washing Use of 2% chlorhexidine as skin antiseptic Appropriate dressing of the exit site Disinfection of hubs, stopcocks and needle-free connectors Regular change of administration sets
B
6
Some interventions are not effective in reducing the risk of infection, and should not be adopted for this purpose; these include:
in-line filters routine replacement of central lines on a scheduled basis antibiotic prophylaxis the use of heparin
Diagnosis of catheter-related sepsis Diagnosis of CRBSI is best achieved (a) by quantitative or semi-quantitative culture of the catheter (when the A
7
CVC is removed or exchanged over a guide wire), or (b) by paired quantitative blood cultures or paired
qualitative blood cultures from a peripheral vein and from the catheter, with continuously monitoring of the
differential time to positivity (if the catheter is left in place).
M. Pittiruti et al. / Clinical Nutrition 28 (2009) 365?377
367
Table (continued) Summary of statements: Central Venous Catheters
Subject
Recommendations
Grade Number
Treatment of catheter-related sepsis A short-term central line should be removed in the case of (a) evident signs of local infection at the exit site, (b) B
8
(short-term lines)
clinical signs of sepsis, (c) positive culture of the catheter exchanged over guide wire, or (d) positive paired
blood cultures (from peripheral blood and blood drawn from the catheter). Appropriate antibiotic therapy
should be continued after catheter removal.
Treatment of catheter-related sepsis Removal of the long-term venous access is required in case of (a) tunnel infection or port abscess, (b) clinical B
9
(long-term lines)
signs of septic shock, (c) paired blood cultures positive for fungi or highly virulent bacteria, and/or (d)
complicated infection (e.g., evidence of endocarditis, septic thrombosis, or other metastatic infections). In
other cases, an attempt to save the device may be tried, using the antibiotic lock technique.
Routine care of central catheters
Most central venous access devices for PN can be safely flushed and locked with saline solution when not in C
10
use.
Heparinized solutions may be used as a lock (after flushing with saline), when recommended by the
manufacturer, in the case of implanted ports or opened-ended catheter lumens which are scheduled to remain
closed for more than 8 h.
Prevention of line occlusion
Intraluminal obstruction of the central venous access can be prevented by appropriate nursing protocols in C
11
maintenance of the line, including the use of nutritional pumps.
Prevention of catheter-related central venous thrombosis
Thrombosis is avoided by the use of insertion techniques designed to limit damage to the vein, including
B
12
Ultrasound guidance at insertion
choice of a catheter with the smallest caliber compatible with the infusion therapy needed
position of the tip of the catheter at or near to the atrio-caval junction
Prophylaxis with a daily subcutaneous dose of low molecular weight heparin is effective only in patients at high risk for thrombosis.
Home PN should not be given only via short catheters, as these carry a high risk of dislocation and complications (Grade C).
Peripheral PN, whether through short cannulas or midline catheters, demands careful surveillance for thrombophlebitis (Grade C).
Comments: There is not enough evidence in the literature to indicate a clear cut-off osmolarity for central versus peripheral PN, and experimental data obtained in animal models are not completely transferable to humans.1 Central venous access is usually indicated in the following conditions: administration of solutions with pH < 5 or pH > 9; administration of drugs with osmolarity >600 mOsm/L (INS 2006) or 500 mOsm/L; PN with solution whose osmolarity is equal or superior to 10% glucose or 5% aminoacids; administration of vesicant drugs or drugs associated with intimal damage; need for multiple lumen intravenous treatment; need for dialysis/apheresis; need for central venous pressure monitoring; venous access needed for > 3 months. PN whose osmolarity exceeds 800?900 mOsm/L has been widely thought (several guideline statements) to warrant use of a central line, the upper limit based on a clinical study published 30 years ago.2 However, in another clinical study on this subject it proved possible to give PN with an osmolality around 1100 mOsm/kg for up to 10 days via peripheral veins in most patients.3 In short-term PN, increasing osmolarity did not increase the incidence of thrombophlebitis and did not affect the success rate of lines.4 Also, it appears that the risk of thrombophlebitis is related not only to the osmolarity, but also to the lipid content ? which may have a protective effect on the endothelium5 ? and to the final pH of the solution. Finally, volume load and osmolarity appear to have equal relevance in determining phlebitis: the osmolarity rate, defined as the number of milliOsmols infused per hour, correlated well with the phlebitis rate (r ? 0.95) in clinical trial.6
Thus, more randomized studies are needed, to clarify the range of indication of peripheral PN, especially considering the increasing use of peripheral lines which can stay safely in place for weeks (midline catheters). These are 20?25 cm long polyurethane or silicone catheters, whose diameter is usually between 3 and 5 Fr, inserted1 in the superficial veins of the antecubital area, by a simple
percutaneous technique, or2 in the deep veins of the midarm, with ultrasound guidance.
Midline catheters should be taken into consideration as a potential option every time that peripheral therapy is expected for more than 6 days (Grade B). Since this is the case for most inhospital PN treatments, midline catheters are bound to play a major role in this setting. In the case of home PN, short cannulas carry a high risk of dislocation and infiltration, so in the unusual event of home peripheral PN being indicated it should be delivered through midline catheters.
Nonetheless, it is important to stress that peripheral PN, both through short cannulas and through midline catheters, has major limitations (a) in the availability of peripheral veins and (b) in the risk of peripheral vein thrombophlebitis.7 The first problem can be overcome by the routine use of ultrasound guidance, which allows positioning of midline catheters in deep veins of the upper arm (basilic and brachial) even when no superficial veins can be found. The prevention of peripheral vein thrombophlebitis is based on several interventions: aseptic technique during catheter placement and catheter care; choice of the smallest gauge possible (ideally, the diameter of the catheter should be one third or less of the diameter of the vein, as checked by ultrasound); use of polyurethane (PUR) and silicone catheters rather than Teflon cannulas; appropriate osmolarity of the solution; use of lipidbased solutions (fat emulsion may have a protective effect on the vein wall); pH higher than 5 and lower than 9; adequate fixation of the catheter (by transparent adhesive membranes and/or sutureless fixation devices).
2. How to choose the central venous access device for PN?
Short-term: many non-tunneled central venous catheters (CVCs), as well as peripherally inserted central catheters (PICCs) are suitable for in-patient PN.
Medium-term: PICCs, Hohn catheters, and tunneled catheters and ports are appropriate. Non-tunneled central venous catheters are discouraged in HPN, because of high rates of infection, obstruction, dislocation, and venous thrombosis (Grade B).
368
M. Pittiruti et al. / Clinical Nutrition 28 (2009) 365?377
Prolonged use and HPN (>3 months) usually require a longterm device. There is a choice between tunneled catheters and totally implantable device. In those requiring frequent (daily) access a tunneled device is generally preferable (Grade B).
High approaches to the internal jugular vein (either anterior or posterior to the sternoclavicular muscle) are not recommended, since the exit site is difficult to nurse, and there is thus a high risk of catheter contamination and catheter-related infection (Grade C).
Comments: Central venous access devices (i.e., venous devices whose tip is centrally placed) can be classified as those used for short-, medium- and long-term access.
Short-term central catheters are usually non-tunneled, 20? 30 cm polyurethane (PUR) catheters inserted in a central vein (subclavian vein, internal jugular vein, innominate vein, axillary vein or femoral vein); they may have a single-lumen or multiple lumens; they are designed for continuous use and they should normally be used only in hospitalized patients,8 for a limited period of time (days to weeks).
Medium-term central catheters are usually non-tunneled central venous devices intended for discontinuous use: they include PICCs (peripherally inserted central catheters) and non-tunneled centrally inserted silicone catheters (such as Hohn catheters). PICCs are nontunneled central catheters inserted through a peripheral vein of the arm (basilic, brachial or cephalic); they are 50?60 cm in length and usually made of silicone or PUR. Hohn catheters are non-tunneled 20 cm centrally inserted silicon catheters.9 Both PICCs and Hohn catheters can be used for prolonged parenteral nutrition (up to 3 months) in hospitalized patients and in non-hospitalized patients treated in day hospitals, in hospices or at home.8 PICCs are acceptable for short?medium-term HPN, but ? since the exit position effectively disables one hand ? self care may be difficult.
With regards to PN in the hospitalized patient, there are no clear data showing significant advantages of PICCs versus centrally inserted CVC. Some evidence suggests that PICC use may be preferable because associated with fewer mechanical complications at insertion, lower costs of insertion, and a lower rate of infection.9,10 Although this last issue is under debate,11 it is accepted that placement in the antecubital fossa or the midarm carries the important advantage of removing the exit site of the catheter further away from endotracheal, oral and nasal secretions (Grade C).
Long-term (>3 months) home parenteral nutrition (HPN) requires a long-term venous access device, such as a cuffed tunneled central catheter (Hickman, Broviac, Groshong, and Hickman-like catheters such as Lifecath, RedoTPN, etc.) or a totally implanted port. The choice between tunneled catheters and ports depends on many factors, mainly related to patient's compliance and choice, the experience of the nursing staff, and the frequency of venous access required. Implantable access devices have been recommended only for patients who require long-term, intermittent vascular access, while for patients requiring long-term frequent or continuous access, a tunneled CVC is preferable, but the evidence base for this is weak (Grade C).
Arteriovenous fistulae have been used episodically as a route for delivery of long-term home PN, when central venous access had become impossible; there is insufficient evidence to give recommendations in this regard.
b) Insertion of central venous access devices
3. Which is the preferred site for placement of a central venous access device?
The choice of vein is affected by several factors including venepuncture technique, the risk of related mechanical complications, the feasibility of appropriate nursing of the catheter site, and the risk of thrombotic and infective complications (Grade B).
The use of the femoral vein for PN is relatively contraindicated, since this is associated with a high risk of contamination at the exit site at the groin, and a high risk of venous thrombosis (Grade B).
Comments: Short-term non-tunneled CVC and Hohn catheters are inserted by percutaneous venepuncture of central veins, either by the so-called `blind' method (using anatomical landmarks) or by ultrasound (US) guidance/ assistance.
Blind positioning of CVCs is usually achieved by direct venepuncture of the subclavian vein (via a supraclavicular or infraclavicular approach), or the internal jugular vein (high posterior approach; high anterior approach; axial approach, between the two heads of the sternoclavicular muscle; low lateral approach; etc.); or the femoral vein. Venepuncture of the internal jugular vein carries less risk of insertion-related complications if compared to the subclavian vein12; in particular, the low lateral approach to the internal jugular vein (or Jernigan's approach) appears to be the technique of blind venepuncture associated with the lowest risk of mechanical complications.13
US-guided positioning of short-term CVCs may be achieved by supraclavicular venepuncture of the subclavian vein, of the internal jugular vein, or of the innominate vein; by infraclavicular venepuncture of the axillary/subclavian vein; or by femoral venepuncture.
Though positioning of central venous catheters on the left side is usually associated with a higher risk of malposition than on the right side, there are no evidence-based recommendations in this regard. Also (a) there may be specific clinical and anatomic conditions which enforce use of one or other side (poor visualization of the veins on the other side, skin abnormalities, etc.), and (b) the risk of malposition may be minimized by using a technique for intraoperative control of the position of the catheter tip (including fluoroscopy and ECG-based methods).
Since the presence of a non-tunneled CVC in the femoral vein is associated with a high risk of infection and of catheter-related venous thrombosis, this route is relatively contraindicated in parenteral nutrition (Grade C).
Increased difficulty in nursing of the exit site of the catheter is to be expected when the exit site of the CVC is in the neck area14; therefore, it is preferable to employ approaches that facilitate dressing changes, such as the infraclavicular area (subclavian or axillary venepuncture) or the area just above the clavicle (low approach to the internal jugular vein; supraclavicular approach to the innominate vein or to the internal jugular vein).
4. Which is the best technique for placement of a central venous access?
There is compelling evidence that ultrasound-guided venepuncture (by real-time ultrasonography) is associated with a lower incidence of complications and a higher rate of success than `blind' venepuncture. Ultrasound support is therefore strongly recommended for all CVC insertions (Grade A). Placement by surgical cutdown is not recommended, in terms of cost-effectiveness and risk of infection (Grade A).
Comments: The advantages of US-guidance for placement of CVCs have been demonstrated in many RCTs and confirmed by all the meta-analyses on this subject. In a 1996 meta-analysis of eight RCTs, US-guidance was characterized by a lower rate of failure and complications and by a higher rate of success at the first attempt if compared to the landmark technique.15 In 2001, the Stanford Evidence Based Practice Center at the UCSF published the results of the project `Making Health Care Safer: A critical analysis of patient
M. Pittiruti et al. / Clinical Nutrition 28 (2009) 365?377
369
safety practices', identifying US-guidance for CVC placement as one of eleven evidence-based clinical tools which should be enforced in clinical practice.16 In 2002 the British National Institute for Clinical Excellence made the following recommendations: `imaging USguidance should be the preferred method when inserting a CVC into the internal jugular vein in adults and children in elective situations' and that `imaging US-guidance should be considered in most clinical situations where CVC insertion is necessary, whether the situation is elective or an emergency' (Table 1). A meta-analysis of 18 RCTs showed that US-guidance is highly effective in reducing the rate of failure, the rate of complications, and the rate of accidental arterial puncture, thus `clearly improving patient safety'.17 Similar results were shown in a 2003 meta-analysis,18 which also showed that US-guided venepuncture takes less time to perform than blind venepuncture. The same authors concluded that `economic modeling indicates that US is likely to save health service resources as well as improve failure and complication rates,' and that `for every 1000 procedures, a resource saving of ?2000 (w2200V) is suggested'.19 More recently, several randomized studies have confirmed ? with no exception ? the superiority of USguided venepuncture, not only as an elective procedure, but also in the emergency department.20 A randomized study of US-guided versus blind catheterization of the internal jugular vein in critical care patients showed that US-guidance was also associated with a decrease of catheter-related infections.21 The uniform use of realtime ultrasound guidance for the placement of CVCs is clearly supported by the literature (Grade A).
In summary there is strong statistical evidence to indicate that US-guided insertion of central catheters is more effective and safer than blind techniques in both adults and children. It may therefore now be considered unethical or lacking in common sense to withhold the use of this option.22
In placement of PICCs, percutaneous cannulation of the basilic vein or the brachial vein in the midarm, utilizing ultrasound guidance and the micro-introducer technique, is the preferred option (Grade C).
Comments: PICCs may be inserted either in the antecubital fossa, by `blind' percutaneous cannulation of cephalic or basilic vein, or in the midarm, by ultrasound-guided cannulation of the basilic, brachial or cephalic vein; the results of ultrasound technique are optimal if used in conjunction with the micro-introducer technique. Evidence suggests that US insertion in the midarm significantly increases the rate of success, reduces the incidence of local complications such as thrombophlebitis, and also positively affects the compliance of the patient23?25: US-guided PICC insertion is also recommended in other guidelines.
Long-term venous devices (tunneled catheters or ports) usually consist of large bore silicone catheters, which are particularly prone to malfunction and damage if compressed between the clavicle and the first rib (the so-called `pinch-off syndrome'). Thus, when inserting a long-term venous access, the `blind' infraclavicular approach to the subclavian vein ? and particularly the `medial' infraclavicular approach ? is not recommended. It is noteworthy that US-guided CVC placement does not seem associated with the risk of pinch-off, even when using the infraclavicular approach.
US-guided venepuncture of the internal jugular, subclavian, innominate or axillary vein, plus subcutaneous tunneling to the infraclavicular area, is now the best option for long-term venous access. Other less satisfactory options include `blind' cannulation of internal jugular vein (possibly by the low lateral approach) and surgical cutdown onto the cephalic vein at the delto-pectoral fossa or the external jugular vein in the neck. Surgical cutdown is associated with higher costs and a higher risk of infection when compared to percutaneous venepuncture.26
In selected patients (such as when there is obstruction of the superior vena cava), long-term venous access devices may be placed in the inferior vena cava, by femoral venepuncture: in these cases, the catheter exit site or the port must be placed at a proper distance from the groin, to minimize the risk of contamination.
5. Which is the most appropriate position of the tip of a central venous access for parenteral nutrition?
High osmolarity PN requires central venous access and should be delivered through a catheter whose tip is in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium (Grade A). The position of the tip should preferably be checked during the procedure, especially when an infraclavicular approach to the subclavian vein has been used (Grade C).
Postoperative X-ray is mandatory (a) when the position of the tip has not been checked during the procedure, and/or (b) when the devise been placed using a blind subclavian approach or other technique which carries the risk of pleuropulmonary damage (Grade B).
Comments: For any central venous access (short-, medium- or long-term), the position of the tip of the catheter plays a critical role. The ideal position has been said to be between the lower third of the superior cava vein and the upper third of the right atrium. In fact, evidence shows that infusion of high osmolarity PN in the lower third of the superior vena cava or at the atrio-caval junction is associated with the least incidence of mechanical and thrombotic complications. On the other hand, if the catheter is too deep into the atrium, in proximity to the tricuspid valve, or even deeper, it may be associated with these complications.
Ideally, the position of the tip should be checked during the procedure,27 either by fluoroscopy or by the ECG method.28,29 If the position has not been checked intraoperatively, a post-procedural chest X-ray should be performed to check the position of the tip. A chest X-ray should always be performed if the venepuncture has been performed by the `blind' technique, and especially so with an approach which carries the risk of pleuro-pulmonary damage (pneumothorax, hemothorax, etc.). A very early X-ray (within 1 h after the procedure) may not be sufficient, since a pneumothorax may not become apparent for 12?24 h.
c) Prevention of catheter-related bloodstream infections
6. Which evidence-based interventions effectively reduce the risk of catheter-related bloodstream infections?
There is limited evidence to suggest that the catheter material is important in the etiology of catheter-related sepsis. Teflon, silicone and polyurethane (PUR) have been associated with fewer infections than polyvinyl chloride or polyethylene. Currently all available CVCs are made either of PUR (short-term and mediumterm) or silicone (medium-term and long-term); no specific recommendation for clinical practice is made.
Evidence indicates that the risk of catheter-related infection is reduced by:
Using tunneled and implanted catheters (value only confirmed in long-term use)
Using antimicrobial coated catheters (value only shown in short-term use)
Using single-lumen catheters Using peripheral access (PICC) when possible Appropriate choice of the insertion site Ultrasound-guided venepuncture
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- espen guideline on home parenteral nutrition
- parenteral nutrition pocketbook
- parenteral nutrition manual for adults in health care
- espen guidelines on parenteral nutrition central venous
- parenteral nutrition clinical guideline
- organ transplant surveys interpretive guidelines
- total parenteral nutrition in
- organization of nutritional support within hospitals
- intestinal failure referral form
- south tees hospitals nhs trust nice
Related searches
- central venous blood gas interpretation
- central venous stenosis icd 10
- central venous occlusion icd 10
- non tunneled central venous catheters
- espen guidelines on enteral nutrition
- central venous catheter icd 10
- total parenteral nutrition status icd 10
- icd 10 total parenteral nutrition therapy
- total parenteral nutrition guidelines tpn
- icd 10 parenteral nutrition status
- parenteral nutrition icd 10 code
- total parenteral nutrition calculation